Was your spouse/dependant(s) covered within the last 12 months or are they presently covered under another group EHC or dental plan?

ADD SPOUSE AND/ORDEPENDANT COVERAGE

(FOR EXTENDED HEALTHCARE AND DENTAL)

PERSON ID

PART A—PERSONAL INFORMATION (must be completed)HOME PHONE (include ten digits)RETIRED MEMBER LAST NAME

YYYY—MM—DD

EMAIL (optional)

FIRST NAME MIDDLE INITIAL

DATE OF BIRTH

PART C—OTHER COVERAGEComplete this section if you previously waived coverage for yourspouse/dependant(s) and are applying after the 60-day enrolment period.

YES, complete belowNO

INSURANCE COMPANY NAME GROUP / POLICY NO. ID / CERTIFICATE NO.

BENEFITS COVERED UNDER OTHER PLAN

DENTALEHC

IS THE PLAN STILL ACTIVE

NO, termination dateYES YYYY—MM—DD

SPOUSE —Complete if adding spouse

YYYY—MM—DD

Attach a separate sheet to specify additional dependants. To be valid, the additional sheet must include your printed name and signature, dated with the same date written on this form.

Complete if child is over age 19, under age 25 and attending school full time, or is disabled.If adding a child other than your natural child, provide the date you legally became the child's guardian and attach legal documents.

***

FOR OFFICE USE ONLY

RESIDENTIAL ADDRESS (include apt. #, if applicable)

MAILING ADDRESS (include apt. #, if applicable)

PROVINCE POSTAL CODECITY

PROVINCE POSTAL CODECITY

PC/PSPP 2004-023 (Page 1) 2020.06.18

Public Service Pension Plan PO Box 9460Victoria, BC V8W 9V8

Web: pspp.pensionsbc.ca

Toll-free (Canada & U.S.): 1-866-876-6777

DATE OF MARRIAGE (attach copy of marriage certificate if marriage occurred within 60 days of submitting this form)

DATE COMMENCED LIVING TOGETHER IN A MARRIAGE-LIKE RELATIONSHIP (see page 2 "What you need to know" for eligibility)

DATE PERMANENT RESIDENCY GRANTED (attach copy of permanent residency document and see page 2 "What you need to know" for eligibility)

OR

OR

Freedom of Information and Protection of Privacy Act–The personal information on this form is collected under the authority of the Public Sector Pension Plans Act and will be used by the BC Pension Corporation to administer a plan member’s benefits. If you have any questions about the collection and use of this information, contact the privacy officer at PO Box 9460, Victoria BC V8W 9V8 or by telephone at 250-387-1002.

INSTRUCTIONS FOR PLAN MEMBER• Complete if you are a retired member and have existing coverage and would like to add

a spouse/dependant(s).• Completed form must be received in Public Service Pension Plan within 60 days of

eligibility.

• Once completed, sign and return the form to our office by mail.• See page 2 for important information.

C O N T I N U E D O N P A G E 2

MALE FEMALE

GENDER

X

GENDER

PART B—SPOUSE/DEPENDANT COVERAGE INFORMATION (check Extended Health Care (EHC)/Dental box(es) for each spouse/dependant if applying for coverage)

Spouse

First child

FIRST NAME LAST NAMEDATE OF BIRTH

(YYYY–MM–DD)EHC DENTAL

MIDDLE INITIAL

NAME OF SCHOOL AND TERM START DATEOR DETAILS OF DISABILITY, OR ADOPTION * **

Second child MALE

FEMALE

X

MALE

FEMALE

X

MALE

FEMALE

X

PC/PSPP 2004-023 (Page 2) 2020.06.18

Retired Member: Make a copy for your records. Return original to pension plan.

What you need to know• Your spouse and/or dependants must apply for medical

coverage under the provincial health insurance plan.• Continuous coverage since your retirement date is a condition

of eligibility for spouse/dependant(s). For the purpose of this application, we require the details of insurance coverage for the past 12 months only.

• Coverage will be effective the first of the month following cancellation of previous coverage.

• If adding a new spouse and/or dependant you must apply within 60 days of:- your spouse or dependant becoming a permanent resident of

Canada, or - termination of their benefits coverage under another plan, or - the date upon which you married or remarried (copy of

marriage certificate required), or

- the date upon which you and your common-law spouse have lived together for 12 months, or

- the date upon which an individual became your dependant (copy of legal document required), or

- the date upon which an individual commences post-secondary studies.

• Coverage will be effective the first of the month following their eligibility date, except students whose coverage will be effective in the month they become eligible.

• Your spouse and/or dependant(s) must participate in the dental plan for a minimum of 12 months.

• Some provinces charge tax on voluntary dental insurance premiums.

• For more information visit our website at pspp.pensionsbc.ca.

Spouse: A spouse is a person whom you are married to or living with in a marriage-like relationship.If you are in a common-law relationship, you must live together for 12 months before being eligible to apply for extended health benefits and dental coverage for your spouse (unless you are claiming your spouse’s children as dependants on your income tax return). If in a common-law relationship, you may be required to provide proof that you have been living in a common-law relationship for 12 months or more. If you leave one common-law relationship and enter another, you must wait 12 months after cancelling coverage for your first spouse and dependants before you can enrol another spouse and other dependants.Your spouse is not entitled to health benefits if they are separated from you for other than health reasons.

Definition of Spouse and Dependants (for extended health and dental purposes)

• not working more than 30 hours per week on a permanent (year-round) basis,

• not married or not living in a marriage-like relationship as common law,

• under 19 years of age, or under 25 years of age and attending an accredited school or university full time (minimum three courses per semester, including co-op programs, and online and correspondence courses) in a program leading toward a diploma, degree or certificate recognized in Canada (proof of school attendance will be required), or

• of any age with a mental or physical disability and accepted as a dependant for income tax purposes. The pension plan will verify eligibility with Green Shield Canada for disabled dependant(s).

Dependent child: A dependent child may be your natural child, stepchild, adopted child or legal ward (requires a court order, attach a copy). A dependent child must also be:

PART D—CONSENT AND SIGNATURE

RETIRED MEMBER SIGNATURE(must be completed)

DATE SIGNED

YYYY—MM—DD

By signing this enrolment form or providing my personal information to the Pension Corporation, I confirm that the information is complete and accurate to the best of my knowledge. I am authorized to release personal information concerning my spouse and my dependants, for purposes of determining eligibility for benefits and any other services necessary in the administration of my benefits. I certify that I am authorized by my spouse and/or dependants to disclose and receive personal information about them that is used for these purposes. I agree that the Pension Corporation may share the personal information with Green Shield Canada, and Green Shield Canada may share the personal information with a third party for the administration of benefits for myself and my dependants. I agree that my email address may be used, if provided, to correspond with me for benefit purposes.

For information on the privacy policies of the Pension Corporation, visit pspp.pensionsbc.ca. For information on Green Shield Canada's Privacy Policy visit greenshield.ca/en-ca/privacy-policy or call Green Shield Canada at 1 888 711-1119.I understand group benefit coverage is a contingent benefit of the plan. That is, the EHC and dental benefits are not guaranteed. The coverage may be changed at any time by the Public Service Pension Board of Trustees, including, but not necessarily limited to, increasing, decreasing or eliminating (a) coverage for people and benefits, or (b) amounts for premiums and deductibles. If my pension payment is sufficient to cover my premium(s), I authorize the Public Service Pension Plan to deduct this amount from my pension cheque. If I should receive a settlement or a judgment against a liable third party for benefits covered under my group plan, I agree to and authorize the third party to reimburse Green Shield Canada up to the amount advanced to me pending such settlement or judgment.